Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Intervention Ch. 48
Wounds
| Question | Answer |
|---|---|
| Skin is the bodies largest? | Organ |
| The skin a protective barrier against? | disease causing organisms, a sensory organ for pain, temperature, and touch, and it synthesizes Vitamin D |
| What are the 2 layers of the skin? | epidermis and the dermis |
| What is the membrane that seperates them? | the dermal-epidermal junction |
| The epidermis has? | several layers |
| What is the outermost layerr of the epidermis? | stratum corneum |
| What is the innermost epidermal layer? | basal layer |
| Cells in the basal layer? | divide, proliferate, and migrate toward the epidermal surface |
| What does the stratum corneum protect underlying cells and tissues from? | dehydration, and prevents entrance of certain chemical agents |
| What does the dermis provide? | strength, mechanical support and protection to the underlying muscles, bones and organs. |
| How doe sthe dermis differ from the epidermis? | is contains mostly connective tissue and few skin cells |
| What is collagen? | a tough, fibrous protein |
| What are responsible for collagen formation? | fibroblasts |
| What does age do to skin? | it makes skin more vulnerable to damage |
| What is a pressure ulcer? | localized injury to the skin and other underlying tissue, usually over a body prominence, pressure and friction |
| Who is at risk for pressure ulcers? | decreased mobility, decreased sensory perception, incontinence, and poor nutrition |
| prolonged intense pressure affects? | cellular metabolism by decreasing or obliterating blood flow, resulting in tissue ishemia and then tissue death |
| What are the 3 pressure related factors contributing to pressure ulcer development? | 1. pressure intensity, 2. pressure duration, 3. tissue tolerance |
| If a capillary exceeds the normal capillary pressure, and the vessel is occluded for a prolonged period of time what can occur? | tissue ischemia |
| How is tissue ischemia discovered? | pressure is relieved and the blood flow returns means there isn't any, but if you apply pressure and the blood is not returned tissue ischemia is present |
| What is reactive hyperemia? | Where blood returns after pressure on skin |
| What is blanching erythema? | Where blood is not present when there is pressure on skin |
| Blanching does not occur in what pt's? | Dark pigmented skin |
| What is darkly pigmented skin? | skin that remains unchanged when pressure is applied over a bony prominence, iffecpective of the client's race or ethnicity |
| Low pressure or high pressure for a short time causes? | tissue damage |
| prolonged pressue causes? | tissue death |
| As a nurse you should assess what about pressure and the pt? | evaluating the amount of pressure and determining the amount of time that a client tolerates pressure |
| What does the ability of tissue to endure pressure depend on? | integrity of tissue and the supporting structures |
| If the factors of shear, friction, and moisture are present the more susceptible the skin will be to? | damage from pressure |
| Clients with altered sensory perception for pain and pressure are more? | At risk for impaired skin integrity |
| Impaired mobility increases? | risk of pressure ulcer |
| pt's who are confused are unable to protect themselves from? | pressure ulcer |
| What is shear? | the force exerted parallel to skin resulting from both gravity pushing down on the body and resistance between the client and the surface |
| What is friction? | 2 surfaces moving across one another, such as the mechanical force exerted when skin is dragged across a coarse surface |
| Friction affects what? | the epidermis or top layer of the skin |
| What friction has occured the skin will appear? | red and painful "sheet burn" |
| Friction injury occurs is pt's who? | are restless, in those who have uncontrollable movement, and those who have their skin dragged |
| The presence and duration of _____ on the skin increases the risk of ulcer formation? | moisture |
| Prolonged moisture _______ skin and makes it more suseptible | moistens |
| Where does skin moisture originate from? | wound drainage, excessive perspiration, and fecal or uninary incontinence |
| What does an assessment of a pressure ulcer include? | type, depth of involvement, approx. % of tissue in wound bed, wound dimensions, exudate description, and condition of surrouding skin |
| What are staging systems for pressure ulcers? | how deep tissue is destroyed |
| What must be removed to expose the wound so you can stage it? | nectrotic tissue |
| Stage 1: | intact skin with nonblanchable redness of a localized area, usually over a bony prominence |
| Stage 2: | Partial-thickness skin loss involving epidermis, dermis, or both. the ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater |
| Stage 3: | Full thickness tissue loss. subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. slough may be present but does not obscure the depth of tissue loss. may include undermining and tunneling |
| Stage 4: | Full thickness tissue loss with exposed bone, tendon, or muscle. slough or eschar may be present on some parts of the wound.. often includes underming and tunneling |
| What is an unstageable ulcer? | is full thickness tissue loss in which the base of the ulcer is covered by slough or char in the wound bed |
| For a wound with nonaviable tissue you will need to assess? | the type of tissue in the wound base |
| What does the assessment of tissue type include? | amount and apperance of viable and nonviable tissue |
| What is granulation tissue? | red moist tissue composed of new blood vessels, the presence of which indicates progression toward healing. |
| What is soft yellow or white tissue charecteritic of? | slough (stingy substance) |
| What is black and brown nectrotic tissue? | eschar |
| What do you use to measure a wound? | desposable wound measuring devices |
| How do you measure depth of a wound? | used a cotton tipped applicator |
| What is wound exudate? | is describes the amount, color, consistency, and odor of drainage and is part of the wound assessment |
| What does excessive exudate indicate? | the presence of infection |
| What do you assess the tissue around the wound? | redness, warmth, maceration or edema |
| What is a wound? | integrity and function of tissues in the body |
| All wounds are not created? | equal |
| Wound classification systems describe? | The status of skin, integrity, cause of the wound, severity or extent of tissue injury or damage, cleanliness of the wound, or descriptive qualities of the wound tissue such as color |
| What do wound classifictions allow nurses to do? | enable the nurse to understand the risks accosiated with a wound and implications |
| What are the two types of wounds: | those with loss of tissue and those without |
| What heals with primary intention? | surgical wounds |
| Sugical wounds edges are? | approximated, or closed |
| What heals with secondary intention? | a wound involving loos of tissue, such as a burn, pressure ulcer, or severe lacteration |
| The wound is left open until when? | scar tissue fills it |
| It takes longer for a wound to heal using? | secondary intention |
| what are partial thickness wounds? | shallow wounds involving loss of the epidermis and possibly partial loss of the dermis |
| How does partial thickness wounds heal? | by regeneration |
| Pressure ulcers are an example of what? | full thickness wounds |
| What are the 3 components involved in the healing process of partial thickness wounds? | 1. inflammation, epithelial proliferation and migration, and reestablishment of the epidermal layers |
| A wound left open to air can resurface within? | 6 to 6 days |
| A wound that is kept moist can resurface in? | 4 days |
| Epidermal cells only? | Migrate accross a moist surface |
| In a dry wound the cells? | migrate down to a moist surface until they can migrate |
| New eptthelium is only a few cells thick and must undergo? | restablisment of the epidermal layers |
| What are the 3 phases involved in the healing process of a full thickness wound? | are inflammartory, proliferative, and remodeling |
| What is the inflammatory phase? | the body's reaction to wounding and begins within minutes of injury and last approximately 3 days |
| What happens during hemostatis? | injured blood vessels contrict, and platelets gather to stop bleeding |
| What do clots form? | a fibrin matrix that later provides a framework for cellular repair |
| Damage tissue and mast cells secrete? | histamine |
| Leukocytes reach the wound? | within a few hours |
| What is the primary active white blood cell? | a neutrophil |
| What do neutrophils do? | ingest bacteria and small debris |
| What is the second important leukocyte? | monocyte with transforms into macrophages |
| What to macrophages secrete? | growth factors that attract fibroblasts |
| What is the main component of scar tissue? | collagen |
| Too much imflammation also prolongs healing because? | arriving cells compete for nutrients |
| When does the proliferative phase begin? | with the appearance of new blood vessels |
| How long does it last? | 3-24 days |
| What are the main activities during the proliferation phase? | filling the wound with granulation tissue, contraction of the wound, and the resurfacting of the wound by epithelialization. |
| What synthesizes collagen? | fibroblasts |
| Collagen mixes with granulation tissue and this matrix will support? | reepithelialization |
| What does collagen provide? | strength and structural integrity to a wound |
| In a clean wound the proliferative phase accomplishes what? | the vascular bed is reestablished, the area is filled with replacement tissue, and the surgace is repaired |
| Maturation is the final stage of healing and can take? | 1 year |
| Usually scar tissue contains fewer? | pigmented cells and has a lighter color than normal skin |
| What is hemorrhage? | bleeding from a wound site |
| Hemostasis occurs within several minutes unless? | large blood vessels are involved or the client has poor clotting function |
| Hemorrhage occurs? | externally or internally |
| What is a hematoma? | localized collection of blood underneath the tissues |
| How does a hematoma appear? | a swelling, change in color, sensation or warmth or mass |
| Why is a hematoma bad by a major artery or vein? | it can obstruct blood flow |
| What is the second most common infection? | wound infection |
| How do you know a wound is infected? | purulent material drains from it |
| All chronic dermal wounds are considered? | contaminated with bacteria |
| It is generally agreed that wounds with more than how many organims are infected? | 100,000 |
| Wound infection increases when there is? | necrotic tissue, foreign bodies in the wound, and the blood supply and local tissue defenses are reduced |
| Some wounds show infection in how many days? | 2 or 3 days |
| when does a surgical wound show infection? | 4-5 days |
| How do you know there is an infection? | pt has fever, tenderness, and pain at the wound site, and an elevated WBC count |
| When a wound does not heal properly there is? | skin and tissue seperation |
| What is dehiscence? | the partial or total separation of wound layers |
| A person at risk for poor wound healing is at risk for? | dehisence |
| Who have a greater risk for dehiscence? | obese people |
| You should know that when there is an increase in ___________ drainage from a wound there is a greater risk for dehiscence? | serosanguineous |
| What is a good strategy to prevent dehisence? | using a blanket or pillow over the abdomen site |
| What is eviseration? | total separation of wound layers, where there is protrusion of visceral organs through a wound opening |
| What does the nurse do when eviceration occurs? | the nurse places sterile towels soaked in sterile saline over the sxtruding tissues |
| What is a fistula? | an abnormal passage between two organs or between an organ and the outside of the body |
| What are the common reasons fistula's form? | as a result of poor wound healing or as complication of disease |
| Fistulas increase the? | risk of infection and F&E imbalances |
| Prevention and treatments of ulcers is a? | major nursing priority |
| The norton scale and the braden scale are used for? | pressure ulcer risk assessments |
| What are norton's five risk factors? | physical condition, mental condition, activity, mobility and incontinence; score ranges from 5-20, lower score=high risk |
| What was the braden scale used for? | Nursing homes |
| What are braden's 6 subscales? | sensory perception, moisture, activity, mobility, nutrition, and friction and shear; score ranges from 6 to 23, lower score= higher risk |
| What is the most commonly used assessment scale for pressure ulcer risk? | Braden scale |
| Pressure ulcers usually develop when? | within the first 2 weeks of hospitilization |
| When a pressure ulcer occurs it effects the pt how at the hospital? | the length of stay and the cost increase |
| Normal wound healing requires? | proper nutrition |
| wound healing relies on? | protein and vitamins, zinc and copper |
| What is vitamin C for? | synthesis of collagen |
| What is vitamin A for? | reduce the negative effects of steroids on wound healing |
| What is zinc for? | epithelialization |
| What is copper for? | collagen fiber linking |
| The study of prealbumin provides? | what the pt has eaten, absorbed, digested, and metabolized |
| What fuels that cellular functions essential to the healing process? | oxygen |
| What shows that an infection is present? | pus, odor, volume change, character of wound drainage, redness, fever, and pain |
| Body image changes influence? | self concept and sexuality |
| What factors affect the pt's perception of a wound? | scars, drains, odor from drainage, and temporary or permanent prosthetic device |
| Critical thinking is? | always changing |
| What guides skin assessment? | focusing on specific elements such as the pt's level of sensation, movement, and continence status |
| Pay special attention to skin over? | body prominences, or in a cast |
| Also assess the pt's response to? | pressure |
| When you suspect abnormal reactive hyperemia? | outline the affected area with marker |
| when assessing for pressure ulcers you should? | use appropriate predictive measure and alles the client's mobility, nutrition, presence of body fluids, and comfort level |
| Once you think a person is at risk for pressure ulcer's you should? | implement prevetion stratgies |
| For assessing motility you should? | document muscle tone, stength, and activity tolerance |
| Malnutrition is a major risk factor for? | pressure ulcer development |
| What body fluids give the greatest risk for skin breakdown? | gastric and pancreatic |
| What two conditions do you often assess wounds? | At the time of injury before treatment, and after therapy |
| What is an abrasion? | superficial with little bleeding and is considered a partial thickness wound |
| What is a laceration? | more bleeding because of depth and location |
| What is puncture wounds? | Bleed because depth and size of wound |
| What is the primary danger of puncture wounds? | infections |
| Do not take a dressing off until? | it is ordered |
| When taking off a dressing you should asses whether the? | wounds edges are closed |
| For wound drainage you should note? | the amount, color, odor, and consistency of drainage |
| What are types of drainage? | serous, sanguineous, and serosanguneous, and prulent |
| Why would you incert a drain? | if there is a large amount of drainage |
| What should you assess about drains? | drain placement, character of drainage, condition of collecting equipment |
| A sudden decrease in tubing could be? | a blockage |
| What jackson pratt? | exerts a constant low pressure as long as the suction device is fully compressed |
| If fluid accumulates? | The wound will not heal |
| How are surgical wounds closed? | staples, sutures, and wound closures |
| What are two initial defenses for preventing skin breakdown? | assessment and skin hygeine |
| When cleaning skin do not use? | soap or hot water |
| Clients need respositioned? | every 2 hrs |
| What are support surfaces? | therpeutic beds and mattresses |
| What is the goal of effective wound management? | maintenance of a physiological local wound enviroment |
| to maintain a healthy wound enviroment you should? | manage infections, cleanse the wound, remove nonvialbe tissue, manage exudate, maintain the wound in a moist enviroment, and protect the wound |
| How do you clean a pressure ulcer? | saline or noncytotoxic cleaners |
| What is the most common method of getting solution to a wound? | irrigation |
| What is the epidermis? | top layer of skin |
| What is the dermis? | inner layer (strength, support, blood vessels, collagen, connective tissue) |
| Blanching that stay white may indicate? | deep tissue damage |
| What are the 3 healing processes? | primary, secondary, tertiary |
| How will a partial thickness wound repair? | inflammatory, epithelial proliferation, and migration (LIKE NEW) |
| How will full thickness wound repair? | inflammatory, proliferation and remodeling (SCAR) |
| What are possible things that could go wrong with wounds? | hemorrhage, infection, dehiscence, eviseration, fistla |
| What is the best nursing action for wounds? | PREDICT AND PREVENT |
| What do you assess about a wound? | appearance, drainage, drains, wound closures, palpate wound, culture |
| For a culture you should do what first? | clean the wound |
| How do you prevent wound formatio? | clean skin daily, position, support surfaces |
| If infected a wound? | will not heal |
| What may be necessary for a wound? | debridement or irrigation |
| Excessive exudates are? | bad |
| How do you clean a wound? | center out, be gentle, Ns preferred |
| Pressure ulcers NEED? | dressings |
Created by:
alicia.rennaker
Popular Nursing sets